Hard Tissue Final Flashcards
Metastatic Bone Tumors
Primary Malignant Bone Tumors
General information
m/c malignant tumors of skeleton
• 70% are metastatic in origin
• 30% are primary tumors
• most are mets from a primary extra-skeletal focus- majority are epithelial in origin.
Metastatic Bone Tumors
Primary Malignant Bone Tumors
Most common primary sites of origin
breast • lung * 80% of bone mets • prostate are from these sites • kidney • thyroid • bowel
Metastatic Bone Tumors
Primary Malignant Bone Tumors
Female Metastasis stats
- breast cancer —————-70% bony metastasis
* thyroid, kidney uterus —–30% bony metastasis
Metastatic Bone Tumors
Primary Malignant Bone Tumors
male Metastasis stats
• prostate cancer ————-60% bony metastasis
• lung ————————–20 % bony metastasis
- other ————————-20%
Metastatic bone tumors
Clinical features
• usually 40 or older • recent weight loss • anemic • fever in advanced stages MAJOR--->• principle sign: • persistent nocturnal pain • pathologic fracture
Metastatic bone tumors
Clinical features cont.
• increased serum calcium in osteolytic mets;
however in most cases this is WNL.
- increased alkaline phosphatase and PSA with cancer of the prostate when capsule has been broken and Batson venous plexus has been seeded.
- occurs by direct invasion or seeding.
- not unusual to detect an metastatic lesion 10 to 15 yrs after treatment for a primary lesion
Pathologic Features of Primary Malignant Bone Tumors
Pathways of metastasis
4
• Direct extension— soft tissue tumor lying adjacent to bone
eg; ca of uterus ==> iliac bone
• Lymphatic extension
uncommon because of lack of lymphatic channels- bone
• Hematogenous dissemination
• veins m/c pathway
• thick walls of arteries usually resist
- tumor penetration
- Batson’s venous plexus
- provides passageway for cancer cells to invade bone
Lytic vs. Blastic
Lytic lesions
- tumor emboli into bone marrow
- present a long time
- 50-70% of bone density lost before seen on radiograph
- lytic lesions occurs as a result of pressure erosion from medullary tumor deposits and are unrelated to osteoclastic activity.
*The “L’s”
Lytic, lucent, ladies, loss of bone density
Radiologic features - bone scans 6
- detect 3% to 5% alteration of bone metabolism (mets).
- Tc-99m phosphate or diphosphonate (Tc-99mn-DP) .
- areas of metastasis appear hot = increased uptake.
- up to 40% of pt’s with abnl bone scans have nl x-rays.
- bone scans may detect mets ~ 18 months before they- are seen on x-rays.
- sensitivity 50 to 80% greater than conventional x-rays.
Xray vs Bone Scan differences in bone density sensitivity
A bone scan can detect alterations of as little as 3% to 5%, while on
x-ray ~ 30 – 50% loss of bone density is needed before it can be detected
on x-ray. Detection = “hot” areas.
Most involved part of spine for metastasis
most frequently involved components of the spine are the vertebral bodies and pedicles
metastasis stats
- 28% in the ribs and sternum.
- 39% in the vertebrae.
- 13% in the pelvis.
- 10% in the skull.
- ~ 10% in the long bones.
- mets distal to the knees and elbows are rare.
CT: Computed Tomography
gen info
- more sensitive than x-rays/plain film studies.
- useful in detecting cortical bone involvement.
- useful in detecting associated soft-tissue masses.
MRI: Magnetic Resonance Imaging
gen info
- superior to CT in detection of both bone lesions and adjacentsoft tissue masses.
- infiltration of tumor cells into the fatty marrow is seen as ypointense on T1 weighted images, these areas show yperintense on T2 weighted images.
Fundamental Roentgen Signs 4
• alteration of bone density and architecture
- 75% are osteolytic which is seen as:
- moth-eaten
- permative
- 15% are osteoblastic seen as :
- snowball pattern
- 10% of metastatic lesions are seen as :
- bubbly, highly expansile assoc.. w/ renal or thyroid malignancies
Fundamental Roentgen Signs 3
• vertebral body and pedicles common sites of metastasis
- ivory vertebra seen in:
- Pagets—increased size / enlarged
- Hodgkins Lymphoma — anterior scalloping of vertebral body
• periosteal response is RARE
Primary vs Secondary Tumors
Primary Secondary 30% 70% expands bone periosteal response solitary lesion multiple lesions soft tissue. Mass
Benign tumors
radiolucent lesion
well-defined margins
rim of sclerosis
cortex intact or thickened
may cause bone expansion without cortical destruction
bone adjacent to lesion is normal
short zone of transition
no soft tissue mass
no periosteal reaction or pain
Malignant Tumors
bone destruction- (loss of density)
irregular, ragged, ill-defined- margin
poorly circumscribed areas- of increased density
cortical erosion or destruction
long zone of transition
may have soft tissue mass adjacent- to bone destruction
periosteal reaction
- spiculation - sunburst - laminating - Codman’s triangle
pain irregular cloud of density
Metastatic Bone Tumors
Osteoblastic metastatic carcinoma
clinical features
> 40 yr old males
• persistent nocturnal pain
• weight loss
Osteoblastic metastatic carcinoma
Radiologic features
- increased bone density - radiopacity
- snowball/cotton ball appearance
- vertebral bodies & pedicles common site
- ivory vertebrae
Osteoblastic metastatic carcinoma
Lab
- increased acid phosphatase with prostatic cancer
* possible increased alkaline phosphatase
Osteoblastic metastatic carcinoma
Misc. information
- 15% of metastatic lesions
* usually occurs 10-15 years after surgery or tx of primary - neoplasm (e.g. prostate cancer)
Osteolytic metastatic carcinoma
Clinical features
• 40 + y.o. females
• pain at night
• wt loss
.
Osteolytic metastatic carcinoma
Radiological features 5
- moth-eaten / permeative pattern
- long zone of transition
- vertebral bodies and pedicles commonly effected
- one-eyed pedicles / winking owl sign
- blind vertebra = bilateral lysis of pedicles
Osteolytic metastatic carcinoma
• Misc. info
• 75% of all metastatic carcinoma
• usually occurs 10-15 years after surgery or tx of primary neoplasm (eg. Breast cancer).
• increased serum calcium.
Primary Malignant Bone Tumors
4
- 1 - Multiple myeloma
- 2 - Osteosarcoma
- 3 - Chondrosarcoma
- 4 - Ewing’s sarcoma
Multiple Myeloma
general info
- a.k.a. Kahler’s disease
- • ~ 75% of pt’s are between 50 and 70 yrs of age; mean age 60.
- rarely seen before the age of 40; few cases have been reported below 30.
- male:female 2:1
- m/c primary malignant bone tumor
Multiple Myeloma
clinical features
- 50-70 yr old males.
- pain relieved with bed rest.
- pain aggravated by weight bearing.
- attacks:
- spine m/c
- pelvis
- ribs
- scapula
Multiple Myeloma
labs
- reversed A/G ratio (albumin/globulin)
- 40% show Bence Jones proteinuria
- hypercalcemia is present in ~ 30% (2nd to lytic destruction aused by the myelomatous tissue.)
Multiple Myeloma
radiologic features
- gross osteoporosis (only early sign)
- punched-out lesions = Hallmark of disease
- vertebra plana (uniform collapse)
- raindrop skull (lytic lesions)
- pedicle sign (pedicles visible or preserved on a collapsed vertebra)
Multiple Myeloma
Summary
Solitary plasmacytoma
- represents a localized form of plasma cell proliferation.
- m/c bones affected are mandible, ilium, vertebrae, ribs,- proximal femur and scapula.
- typical lesion has a geographic, soap bubbled, highly
Multiple Myeloma
Summary
Treatment & Prognosis
- 90% die within 3 years.
* tx is radiotherapy with chemotherapy.
Solitary Plasmacytoma 5
gen info
- represents a localized form of plasma cell proliferation.
- is less common than multiple myeloma.
- ~ 50% of pt’s present before the age of 50.
- plasmacytoma is a localized form of multiple myeloma.
- is less aggressive than the diffuse form of multiple myeloma.
Osteosarcoma - a.k.a.
osteogenic sarcoma
Osteosarcoma
gen info 3
• 1º malignant tumor of bone (undifferentiated connective tissue).
• derived from undifferentiated connective tissue
- forms neoplastic osteoid.
• 2nd most common primary malignant tumor.
Osteosarcoma
• 5 clinical types
- central osteosarcoma
- multicentric osteosarcoma
• parosteal osteosarcoma
- (juxtacortical osteosarcoma).
- secondary osteosarcoma
- extraosseous osteosarcoma
Osteosarcoma
Clinical features
- ~75% 10 to 25 yr. old males
- painful swelling of the involved limb
- most common sites:
- distal femur
- proximal tibia
- proximal humerus
Osteosarcoma
lab
- increased alkaline phosphatase
* levels are highest with the sclerotic type
Osteosarcoma
radiological features 6
- ivory or sclerotic medullary lesion in the metaphysis of a -long bone
- “sunburst” / “sunray” periosteal response
- codman’s Reactive Triangle – often
- cortical disruption w/ soft. tissue mass formation
- cumulus cloud formation is the peripheral edge of an eccentric lobulated mass that has roughened and had irregular margins
- TX: amputation (treatment of choice ????)
Chondrosarcoma
gen info
- malignant tumor of chondrogenic origin that remains cartilaginous throughout its evolution.
- third most common primary malignant bone tumor.
Chondrosarcoma
Clinical features
3
- 40-60 year old males.
- pain after development of soft tissue mass - (occurs late in the disease process)
- m/c sites:
* pelvis
* proximal femur
* humerus
* ribs
* scapula
* sternum
* craniofacial bones
* proximal tibia
Chondrosarcoma
Radiologic features 6
- round, oval radiolucencies with ill-defined margins.
- metaphysis or diaphysis.
- popcorn matrix calcification in lesion 2/3’s of time.
- radiolucent lesion 1/3 of time.
- laminated or spiculated periosteal response.
- contours of bone enlarged or expanded.
Chondrosarcoma
Misc. information
• m\c primary malignant bone tumor of scapula.
• of chondrogenic origin and remains essentially
cartilagenous through-out its evolution.
